JLN Process - Pre-authorization

Process Group

Beneficiary Management


  • Provider has secured timely assurance from insurer that proposed service will be admissible for payment through claim settlement

  • Ensure beneficiary beneficiary receives efficient and effective utilization of services

  • Protect payer from unnecessary costs



  • Approval with cost, service or unit boundaries or rejection

  • Approval/ provisional approval (services can proceed but services may not be covered) disapproval

  • Approval percentage (percentage of requests that are approved)

  • Analysis of which services are being rejected (what provider, what services)

Measurable Outcomes

  • Timely response to pre- authorization

  • Approval of (time/cost and or unit based) list of services

  • Financial metrics

  • Fraud resolution

  • Supports quality of care

  • Patient satisfaction

  • Accounts of insurer notified

Task Flow Diagram



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